Public health

The FAST campaign wants you to call 999 if you can answer, about someone you’re with, “yes” to the question “Has their Face fallen on one side?”, “no” to “Can they raise both Arms and keep them there?”, or “yes” to “Is their Speech slurred?” The idea is to get people with strokes to hospital as quickly as possible.

Several readers have been in touch to say that they found the ads on TV frightening and guilt-inducing – had they done enough for a friend or relative who had an evolving stroke? Was it their fault that a stroke progressed as far as it did?

I hope that the effects of these adverts will be investigated, in particular to see if they have any lasting benefit to public health but also to see what the adverse effects are – like what the readers writing to me have experienced.

Indoor swimming pools have many attractions. Heated and disinfected water, private changing space, and even the occasional Jacuzzi on the side. So why would anyone want to swim outdoors? Britain’s seas and rivers are often shockingly cold, and they are also inhabited by all manner of incontinent marine life. Add in the constant threat of exposure to chill winds and rain, and you do not have the ideal ingredients for a pleasant swim. Yet I must confess that I share the enthusiasm of the swimmers of Sandycove near Dublin, who are pictured here.

Even in the northern hemisphere, swimming outdoors has to be one of life’s most satisfying pleasures. It gives you the chance literally to submerge yourself in the beauty of the environment. One of my own favourite places is a bay on the western shore of a small island on the west coast of Scotland, where at sunset the colours of the sky appear to melt into the water.

Outdoor swimming is also brisk, invigorating and fun – and there is no doubt that regular exercise is good for you. The problem is that the medical literature seems filled with terrifying reasons to avoid it. But there is risk everywhere in life, and there are certainly multiple ones in doing no exercise or locking oneself indoors.

Denmark is reported to be paying 40 women compensation after developing breast cancer. The women are being compensated because they were shift workers. It seems that women with a family history of breast cancer are not going to be compensated.

Is this going to be a precedent? How certain can we be that shift work is a carcinogen? There have been concerns for several years, but the problem is that prospective randomised trials to examine potential factors like this are difficult to do. One would need to be sure that it was the shift work, and not factors about the people doing shift work, or the unrelated habits that shift work might lead to, that were the cause. Retrospective studies can at best show an association, rather than causation. The International Agency for Research on Cancer – part of the World Health Organisation – says shift work is “probably” carcinogenic to humans, with “long-term nightworkers” having “a higher risk of breast cancer risk than women who do not work at night. These studies have involved mainly nurses and flight attendants…”

There are plausible biological explanations – involving melatonin – and animal studies that would fit the thesis. But if we want more definite evidence, that means more research.

I was talking to a composer a few weeks ago. “This stuff doesn’t really exist except when it’s played,” he said, pointing to his score with heavy despair. “Whereas you’ve got a job where you can actually see that you are doing something good.” He couldn’t understand that my protests to the contrary were genuine: doctors cannot always be sure that they are making a positive difference.

Medical history is stuffed with examples of bad practice – lobotomy for just about anyone with a mental health problem, tonsillectomy for most people with a sore throat, bed rest for everyone with low back pain. I may exaggerate, but only a little. Even now, we don’t seem to appreciate the value of analysing what we are doing.

The US Senate has just passed a bill putting $1.1bn into research aimed at identifying which medical treatments work and which don’t. This sounds like a good idea, but of course not all research is created equal. Regular readers will be aware, for example, of the conflicts surrounding the Department of Health recommendation that all over-65s receive a flu vaccination. Some evidence supports vaccination, some indicates that it does not improve mortality rates. What to believe?

Autism is not the only developmental disability that a child can be born with. It does, however, garner a lot of attention. Part of the reason is that we still don’t understand the condition as well as we would like. And we still have no way of testing for it through prenatal screening.

Recent research has, however, raised the possibility of such a test. A study published in the British Journal of Psychology showed an association between higher levels of testosterone in amniotic fluid samples and autistic traits in the older child. In light of this information, Simon Baron Cohen, professor of developmental psychopathology at the University of Cambridge, has called for a debate on the ethics of prenatal screening. He is against the practice, as he made clear in an online article in Community Care magazine.

If there is one absolute about screening tests – where testing is done in the absence of symptoms – it is that one has to be extraordinarily careful. The prenatal tests currently available – for Down’s syndrome and spina bifida – are meant to be performed only after appropriate discussion of the potential problems. Yet these tests are still limited in the information they can give us. They do not tell us how disabled the child will be, or what his or her life would be like.

In the UK, smoking in workplaces is banned. But we can do what we want in our own homes and in our own time (as long at it’s legal).

Glancing through job adverts (reading them is a recurrent hobby, not a search) I note that the World Health Organisation wants to recruit only people who are non smokers – that’s not just people who are non-smokers at work, but non-smokers at home as well. This raises an interesting ethical question: should employers have any right to know what their employees are up to (in a non-lawbreaking sense) when they are off duty? Surely employees are entitled to privacy? Of course, good employers will want to ensure that they are not curtailing employees ability to be healthy – but this is a step beyond.

Now, there may be an argument that smokers are less healthy and require more sick leave than non-smokers. But this seems to be rather discriminatory. Most smokers want to stop, and more smokers belong to lower socio-economic groups. I can’t find any research indicating that people would be helped to stop smoking by this policy (if I am wrong, let me know) but there is plenty of evidence associating unemployment with worse health. All in all, this seems to me to be an invasion of privacy and really rather unfair.

Invitations have been pouring through letterboxes all over the UK to take part in the Biobank.

If you haven’t received one already, let me explain what this particular bank wants from you (thankfully, it doesn’t involve money). The Biobank is a research project, and its aim is no less than to improve the “health of future generations”.

Funded by the Medical Research Council, the Wellcome Trust and the Department of Health, among other bodies, it is recruiting half a million people between 40 and 69 to be surveyed about their health. They will be followed for several decades, in some cases until death. People will be asked about health, lifestyle, work, family history, and have blood and urine samples taken for storage. They will also have tests for blood pressure, bone density and lung function. The researchers may ask for permission to access medical notes, and they may in future examine blood for genetic factors.

The snow falls, public transport grinds to a halt, schools are closed, and the Met Office issues “severe weather” warnings.

And death rates go up: as the temperatures drop, so-called “excess winter mortality” kicks in. This phenomenon has been noted in many other countries, too, but why does it happen? A reasonable suggestion is that fuel poverty and cold living conditions cause people to become unwell and a proportion to die. A large study published in the BMJ a few years ago, found that for people aged over 75, being female or having respiratory illness were risk factors for increased mortality. But there was no relationship found between increased mortality and either having trouble heating the house or suffering financial difficulties. In other words, providing winter fuel allowances – which the UK does - was not, according to this study, going to be enough to protect people from excess winter mortality. Interestingly, a study trying to find risk factors for excess winter mortality in New Zealand concluded that there was a ‘surprising’ lack of relationship to commonly supposed risk factors – making it difficult, of course, to know what to do to protect people from it.

In Siberia, there is only excess winter mortality when the temperature dips below 0 degrees C, unlike in Europe where the excess mortality starts above this. So what do they do differently in Siberia? In an interview study of 1,000 Russians, published in the BMJ in 1998, the researchers noted their ability to keep their homes cosy even when outside temperatures dipped below -25 degrees C, and the admirable amount of clothing they wore. The average number of items of clothing was 16, with the average layers of clothing worn being 3.7. This reflects another study published by the Lancet in 1997 which concluded that fewer clothes, less activity and colder homes across Europe were all related to higher mortality.

It is therefore quite nice to not only feel justified in my rather large collection of assorted hats, gloves, scarves, coats, boots and various other apparel which I can now not only consider essential, but can also heartily recommend to others.

When is it time to say “enough”? As Barack Obama settles into the White House, I am hoping that his new surgeon general, widely expected to be CNN’s chief medical correspondent Dr Sanjay Gupta, will decide that with one particular issue, the time has come.

The MMR – measles, mumps and rubella – vaccine is safe. There have been several large-scale studies making this clear. None showed an increased association with autism, which became a big fear among parents in much of the western world, in the wake of the publication of a tiny, flawed research study in The Lancet in 1998.

Measles deaths fell worldwide from an estimated 750,000 in 2000 to 197,000 in 2007. This is thanks to a concerted campaign, run by the Measles Initiative (founded by Unicef, the UN Foundation, the American Red Cross and the Centers for Disease Control and Prevention in the US), which included mass immunisation of children.